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How L.A. County is trying to remake addiction treatment — no more 'business as usual'

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How L.A. County is trying to remake addiction treatment — no more 'business as usual'

Gary Horejsi wrestled with the decision before him, knowing a life could be in his hands.

It was the third time that the woman had used drugs or alcohol since coming to CRI-Help, which runs a 135-bed residential facility in North Hollywood where people are treated for substance use disorder.

CRI-Help needed to be a safe place for people grappling with their addictions. In the past, others had been removed for less. Horejsi, the clinical director, had the final say on whether she should be discharged.

He perused her file on his computer. The woman was still trying, CRI-Help staffers told him. She hadn’t shared drugs with anyone. And if she were to leave, the risks of an overdose were graver than before.

Horejsi decided to let her stay.

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“Things can’t be business as usual anymore,” their chief executive, Brandon Fernandez, later said at a CRI-Help staff meeting. If someone leaves treatment and resumes using drugs the same way they were before, “that could very well look like them dying.”

“So are we going to be willing to do something different?”

“Things can’t be business as usual anymore,” CRI-Help Chief Executive Brandon Fernandez told his staff at a meeting in North Hollywood on April 10.

(Myung J. Chun / Los Angeles Times)

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Fernandez had gathered CRI-Help staff in their North Hollywood conference room to talk about a Los Angeles County initiative that could reshape such decisions. It’s called Reaching the 95% — or R95 — and its goal is to engage with more people than the fraction of Angelenos already getting addiction treatment.

Across the country, more than 48 million people had a drug or alcohol use disorder, according to the latest results from the National Survey on Drug Use and Health. Only 13 million received treatment in the previous year. Among those who did not get treatment, roughly 95% said they did not think that they should.

Those numbers have collided with the grim toll of fentanyl, an especially potent opioid that has driven up deaths across the country. In Los Angeles County, the number of overdose deaths tied to fentanyl skyrocketed between 2016 and 2022, soaring from 109 to 1,910, according to a county report.

“We can’t just take the approach that we’ve been taking and kind of assume that everyone wants the services that we offer,” said Dr. Gary Tsai, director of the Substance Abuse Prevention and Control division at the L.A. County Department of Public Health. “That’s just not the reality.”

His department is trying to nudge addiction treatment facilities to change their approach, by offering financial incentives for those that meet R95 requirements. Among them: changing their rules to not automatically eject people who have a “lapse” of drug use.

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Fernandez, whose organization is participating in R95, said abstinence is still its aspirational goal — and “we still have the ability to use our own clinical judgment on a case-by-case basis,” such as if people endanger other participants. But “we shouldn’t have blanket policies.”

To get R95 funding, they also cannot require people to be totally abstinent before being admitted. And under R95, treatment programs are also being encouraged to partner with syringe programs rooted in “harm reduction” — a philosophy focused on minimizing the harmful effects of drug use — to address the needs of people who may not want to enter or remain in treatment.

Some treatment providers “view us as the enemy instead of as allies,” said Soma Snakeoil, executive director of the Sidewalk Project, which provides Narcan spray to reverse overdoses and other services on L.A.’s Skid Row.

With R95, she said, “the biggest change is that harm reduction organizations and treatment providers are talking to each other in a way that was not happening before.”

A woman wearing gloves gives first aid to a woman on the sidewalk with an open wound on her foot.

Soma Snakeoil, executive director of the Sidewalk Project, gives first aid to a woman with an open wound on her foot last year in Los Angeles.

(Francine Orr / Los Angeles Times)

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The county is also prodding addiction treatment facilities to reexamine whether the way they operate could be turning people away, and look more closely at the “customer experience.” Tsai compared the situation to a restaurant drawing few customers: “How do we get more people in the door?”

Too often, “the drug dealers do a much better job of delivering their product to our patients than we do,” said Dr. Randolph Holmes, chair of government affairs for the California Society of Addiction Medicine.

When Johnny Guerrero decided to get off Skid Row and go into residential treatment in Los Angeles, he was initially turned away because he had arrived “late — maybe 10 minutes late,” the 35-year-old said.

He was only able to get in, he said, because the harm reduction worker who had taken him to the facility let him stay the night at her home, then brought him back the next morning. Even then, “there was so much paperwork. I was so dopesick. There was just hurdle after hurdle after hurdle.”

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“They did not make it easy for an addict to get help,” Guerrero said.

In many cases, “the biggest barrier is just being able to get somebody on the phone” with a treatment provider, said Amanda Cowan, executive director of Community Health Project LA, which provides clean syringes and other services to people who use drugs. “When people are ready, they are ready in that moment.”

As of late March, roughly half of the addiction treatment providers that contract with L.A. County were on track to become “R95 Champions,” which could yield hundreds of thousands of dollars each in additional funding.

A building interior, with a staircase and chairs. In the center two hands hold up a sign reading "We care."

CRI-Help’s George T. Pfleger center in North Hollywood.

(Myung J. Chun / Los Angeles Times)

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To get those funds, they must turn in admissions and discharge policies that adhere to the R95 guidelines, as well as an “engagement policy.” They are also supposed to meet R95 requirements in one other area of their choice, which could include a “customer walkthrough” to see what might turn away clients.

CRI-Help, for instance, had decided to change how it asks newcomers to undergo a search. “The last thing we want to do is trigger someone’s trauma history and potentially have them walk out the door,” Fernandez said.

To ensure it was consistently done with sensitivity, CRI-Help drew up a script for staffers, emphasizing that consenting to a search would help maintain a safe facility. The hope is that “they feel they’re doing something as a part of a community — versus being forced to undergo something that’s uncomfortable.”

Staffers also tell them that if they have any drugs to hand over, “there’s not going to be any consequence, you can still come into treatment,” Fernandez said. “And if we find them on you, there still won’t be any negative consequences.”

The L.A. County push comes as state and federal officials have stressed the need for “low barrier” approaches to addiction care. Even cutting back on drug use can have positive results, researchers have found.

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But some of the changes can be at odds with long-standing beliefs among treatment providers, many of whom got into the field after successfully battling their own addictions in programs firmly focused on abstinence.

Many in the field think “this is what works” because it did work for them, said Vitka Eisen, chief executive of HealthRight 360, another R95 participant. But “we’re the survivors, and we don’t talk to those who didn’t survive.”

Addiction researchers have long called to reexamine how people are treated for substance use disorders. More than a decade ago, a Columbia University center found that “much of what passes for ‘treatment’ of addiction bears little resemblance to the treatment of other health conditions.”

“This is inexcusable given decades of accumulated scientific evidence attesting to the fact that addiction is a brain disease,” the National Center on Addiction and Substance Abuse lamented in its report.

Experts argue that part of the problem is that addiction treatment has long been separated from the rest of the healthcare system. Richard Rawson, senior advisor to UCLA Integrated Substance Abuse Programs, said a major shift was the emergence of buprenorphine, a medication for opioid addiction that could be prescribed in ordinary clinics just like medicines for other chronic conditions.

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But some Southern California treatment providers have viewed using buprenorphine and other such medications as short of sobriety, UC San Diego researchers found — even as California has ushered in requirements for licensed treatment facilities to either offer or help people access such medications.

Addiction is now much more widely understood as a medical condition, but “how much of that philosophy actually gets down to the level of the counselor?” Rawson said. “I think that’s still a work in progress.”

Tsai said a challenge in rolling out R95 is the ingrained idea that “you’re ready or not” for substance use treatment. But “we don’t actually treat any other health condition that way,” he said. “You don’t tell someone with diabetes, ‘Your blood sugar has to be completely under control, and then you’ll be ready for treatment.’”

In North Hollywood, counselors and other CRI-Help employees seated around the conference table studied the R95 goals printed on an L.A. County handout. One staffer said she was struggling with a specific statement, particularly for people in a residential setting: “Requiring abstinence is too high of a bar” for treatment.

Fernandez decided to share his own story. More than a decade ago, he was struggling with drug use, which had worsened after the death of his father. He was unemployed and didn’t have a stable place to live. When an outpatient counselor suggested residential treatment, he initially brushed off the suggestion.

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A person looks over papers while seated at a conference room table

CRI-Help’s staffers had questions and concerns about the changing approach to addiction treatment but ultimately seemed supportive.

(Myung J. Chun / Los Angeles Times)

He changed his mind after a “tough weekend,” but had no intention of abstaining from all drugs in the long term. Fernandez said he was nonetheless welcomed at CRI-Help: “Let’s just help you out for now.”

“I came here begrudgingly with a total attitude that I was going to continue smoking weed when I left treatment. I definitely wasn’t going to stop drinking,” even as he recognized that other things he was doing might be a problem, Fernandez told the CRI-Help employees.

Among those who had gone to treatment, he asked the group, “were you ready for total abstinence on Day One?”

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“No. That wasn’t even my plan,” the same staffer replied with a rueful laugh.

Still, she and others were anxious about how they would keep everyone safe if clients used drugs, especially if they tried to bring them into the facility. “That worries me a little bit,” she said.

“It worries me too,” Fernandez said.

What preoccupies CRI-Help staff is how to balance the needs of people who have had a “lapse” into drug use with maintaining a safe environment for other clients grappling with addiction.

Horejsi said in an interview that whenever someone uses — even if they don’t share their drugs — “everyone knows, and that in itself does have an effect on people. Sometimes people will feel less safe.”

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But Horejsi stressed to the group that “we’re already not discharging people for using” alone.

When people have relapsed, the North Hollywood center has monitored them one-on-one in its television room until staff are sure they are safe, then decided on their next steps. Some have ultimately been moved to another CRI-Help residential facility to continue getting treatment and have a “fresh start,” he said.

The clinical director also urged his co-workers to look back at the many changes CRI-Help had already undergone, such as starting to offer medication for addiction treatment. He reminded them that years ago, CRI-Help clients could be discharged if a doctor had given them an opioid pill at the hospital.

A woman speaks

Mary Grayson, a longtime staff member at CRI-Help, spoke positively of the organizations changes over the years.

(Myung J. Chun / Los Angeles Times)

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“What about when we discharged people because they talked about getting — they glorified drugs?” said Mary Grayson, a longtime CRI-Help employee.

Leaning forward in her seat, Grayson reminded her co-workers that “CRI-Help is not what it was when I walked through those doors 25 years ago — thank God!”

It started with “two shacks on this property. Two raggedy shacks. And look at where we are now,” she said. “Without us changing and growing, we won’t be able to be who we are.”

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Hospital visits for smoke inhalation spiked during Boyle Heights warehouse fire

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Hospital visits for smoke inhalation spiked during Boyle Heights warehouse fire

The number of Angelenos who went to the hospital with throat pain and concerns about smoke inhalation spiked as a fire burned through the massive Lineage cold storage warehouse in Boyle Heights this month, The Times has learned.

The blaze burned for eight days beginning June 17 and involved solar panels, insulation foam and other industrial materials.

During that time, more than three times as many people went to emergency departments within 10 miles of the warehouse mentioning the fire or smoke inhalation compared with the two weeks prior, according to data from the Los Angeles County Department of Public Health obtained through a public records request.

The agency also noted a near doubling of patients mentioning throat pain within five miles of the fire June 21 — 1.9 times the baseline levels.

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Usually, fewer than 50 people go to the emergency room each day for throat pain, and fewer than 20 people for smoke inhalation, the department said.

The hospitalization data was tracked through the department’s syndromic surveillance project, which monitors trends in what people report when they come to emergency departments in L.A. County, as well as diagnosis codes noted by providers. The system is not as comprehensive as full patient health records, and clinicians may not always include key words about “fire,” “smoke” or other circumstantial information in their diagnoses, the public health department said.

As such, it “cannot capture the true number of [emergency department] visits related to symptoms from the fire and likely underestimates the true burden of fire related symptoms,” the department said.

Perhaps unexpectedly, the department said it did not note a substantial increase in asthma, acute respiratory symptoms or chronic obstructive pulmonary disease-related emergency department visits during the fire.

But even these preliminary findings are concerning, experts said. The fire is believed to have started on the solar array on the roof of the 500,000 square-foot building, which housed 85 million pounds of frozen food. It then reached an ammonia line, prompting two brief shelter-in-place orders for nearby residents.

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Over the next week, the fire continued to burn through dense insulation foam within the building’s walls and other unknown industrial materials, blanketing much of L.A. in acrid smoke. Residents in downtown L.A., northeast L.A., Burbank, the San Gabriel Valley and many other parts of the city and county reported seeing and smelling the fumes.

The South Coast Air Quality Management District issued multiple warnings about unhealthy levels of PM 2.5, or fine particulate matter. The city and county opened two smoke respite shelters in the immediate area so that people could breath cleaner air.

It is still unclear what exactly was in the smoke that people breathed in. Industrial fires release far more materials than the burned wood smoke that is emitted during wildfires.

“The makeup of the smoke can include toxic chemicals, fine particles and other serious risks to lung health depending on fire conditions and what is burned,” Will Barrett, assistant vice president for nationwide clean air policy at the American Lung Assn., said as the fire was burning. Children and elderly people are particularly at risk.

David Eisenman, director of the UCLA Center for Public Health and Disasters, said urban industrial fires also can represent a hazard that standard PM 2.5 warnings don’t always address. Those advisories are “blunt instruments” that don’t adequately capture emissions from burning man-made goods — or convey that the source of pollution may include burning batteries or toxic refrigerants, he said.

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The fact that initial numbers don’t show a spike in asthma attacks is “somewhat reassuring,” Eisenman said. But “people may have gone to their primary care doctors, which this would not capture. This data deserves follow up.”

The air district and the U.S. Environmental Protection Agency deployed air monitors to assess particulate matter, airborne toxic metals and other harmful compounds during the early days of the blaze. The air district said it didn’t find significant levels of air toxics during the first two days of the fire, although it did record significantly elevated concentrations of particulate matter within the plume downwind.

Some of the measurements it took with mobile monitors, which are five-minute snapshots, also showed increased bromine and chlorine, which often are found when buildings burn and were at levels “below short-term health-based exposure thresholds,” the air district said. It began continuous PM 2.5. monitoring at two nearby elementary schools on the third day.

The L.A. Fire Department said it detected low-levels of toxic hydrogen fluoride on the second day of the fire, which can be a byproduct of burning lithium-ion batteries.

Lineage, the tenant-operator of the warehouse, said no concentrations of ammonia were detected in the air at any time.

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“There’s no doubt this fire has had a huge impact on the local community, and we are committed to showing up in every way we can,” company officials wrote in a statement last week. They said Lineage worked closely with the Fire Department during the blaze and delivered masks, air purifiers and other supplies to the community, and will work to ensure the fastest cleanup possible.

The long-term health effects of the fire and its smoke probably won’t be known unless researchers conduct a follow-up study, said Eisenman of UCLA.

For example, there may have been delayed pulmonary effects from the hydrogen fluoride and burning insulation foam that — when combined with the elevated PM 2.5 levels in a dense urban environment — produced health effects that didn’t show up in the emergency room data.

“They will show up in increased primary care office visits and exacerbations of chronic disease over the next few weeks,” he said. “So from a public health standpoint, this fire is not over.”

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Water from Boyle Heights warehouse fire carries foam into L.A. River, sparks testing

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Water from Boyle Heights warehouse fire carries foam into L.A. River, sparks testing

All the water unleashed onto the warehouse fire in Boyle Heights — some of it 480 gallons at a time by helicopter — had to end up somewhere.

That somewhere is the Los Angeles River.

Los Angeles Fire Department crews ripped through 50-foot walls filled with foam insulation to get to the building’s steel skeleton and its storage racks.

Charred chunks of foam have been floating from the burn site, partially blocking storm drains. Now organizers from East Yard Communities for Environmental Justice are teaming up with scientists from UCLA and Columbia University to find out more about what’s in the runoff.

“The community here is really interested in knowing, ‘Are there any contaminants that are potentially making their way down to the L.A. River?’” said Yoshira “Yoshi” Ornelas Van Horne, UCLA assistant professor in environmental health sciences. “We really can’t answer that unless we actually have measures and samples analyzed.”

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Water samples collected directly from the warehouse fire runoff have been shipped to Columbia‘s Multi-Element Trace Analysis Laboratory in New York, which has a spectrometer that can identify trace levels of elements. The lab also has relationships with researchers in Southern California.

1

2 Casey Cooper holds a water sample.

1. Emmanuel Carrera Ruedas, left, and Casey Cooper prep containers to take water samples from the L.A. River. 2. Casey Cooper holds a water sample. (Christina House / Los Angeles Times)

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The data will then come back to UCLA for analysis. For now, the scientists and community advocates only have the money to test for copper, lead and arsenic, Ornelas Van Horne said. Residents have expressed interest in testing for more contaminants.

As the water from the firefighting efforts trickles through the warehouse in rivulets, it forms a stream at the corner of S. Indiana and Noakes streets, that gushed into the storm drain. On a recent visit, the water traversed a smoky 10-foot canyon of charred foam and twisted wall panels on its way to the drain.

From there, the water flows to the L.A. River. Despite the fact that its concrete design is intended to whisk water out of the city as fast as possible, life stubbornly persists in the river and nearby. Recreational swimming is not permitted, yet anglers fishing for tilapia, largemouth bass and carp are a common sight along the rocky sides of the soft-bottom areas.

The L.A. River, and all it carries with it, meets the ocean in Long Beach.

The L.A. County Public Works Department said it has deployed three containment booms — floating barriers — on the L.A. River, and is continuing to monitor the water as it makes its way to the ocean.

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Emmanuel Carrera Ruedas takes a water sample.

Emmanuel Carrera Ruedas takes a water sample.

(Christina House / Los Angeles Times)

Before it gets there, the river passes through the Dominguez wetlands, where Public Works is removing some number of dead fish. The wetland has absorbed toxic runoff from a warehouse fire before, resulting in a fish die-off.

“For so long, the L.A. River has been used as a dumping ground for all kinds of chemicals,” said Emmanuel Carrera Ruedas, a community scientist and member of East Yard Communities for Environmental Justice.

Pollution has plagued the L.A. River, but it does have allies. In the 1980s, the Friends of the LA River pushed to address street runoff and trash that had made the water body infamous. Significant progress from advocacy and government initiatives improved water conditions, but these efforts have not been equally distributed.

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Carrera said the samples represent “proof of what’s actually going on, and accountability, too, for the city, of not just what’s happening in our air, but what’s actually happening in our waterways.”

The first samples for the project were taken last Friday, the second day of the fire.

They were the first of 20 samples the research groups have agreed to test at no cost to see if any exceed regulatory standards and could pose a risk to people nearby.

The warehouse fire represents the latest environmental disaster for people in Boyle Heights and East L.A. Just four weeks ago, a telecommunications crew accidentally struck one of the many oil pipelines beneath the L.A. area, spilling 25,000 gallons of crude oil near Eastern and Cesar Chavez avenues — including into storm drains feeding to the L.A. River.

“I think it really is difficult to see disaster after disaster hit the communities here, with not a lot of talk about how we can move through these disasters together,” said Casey Cooper, a volunteer community scientist involved in the sampling. They were inspired, they said, by the response of neighbors, and how people were supporting one another.

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Results from the laboratory analysis could be back to Ornelas Van Horne within a month.

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EPA touts crackdown on smuggled pesticides in L.A. visit

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EPA touts crackdown on smuggled pesticides in L.A. visit

The U.S. Environmental Protection Agency is ramping up its enforcement of illegal pesticides smuggled through the ports of Long Beach and Los Angeles, officials said during a visit to L.A. on Thursday.

Since President Trump began his second term in January 2025, EPA has blocked more than 2.4 million pounds of illegal pesticides from entering the country, said Lee Zeldin, the agency’s administrator. Much of it comes from China, but some comes from Mexico and, on the East Coast, from Africa.

“We’re very alarmed by any chemical that anyone would seek to bring into this country that our own government hasn’t had the opportunity to vet, to research to fully understand,” Zeldin said. “That’s why it’s so important that these products get stopped at the border.”

The announcement came just hours after the Supreme Court handed a major victory to the makers of the weedkiller Roundup, shielding it from thousands of lawsuits from states alleging the company failed to warn people the product could cause cancer.

Speaking from a U.S. Customs and Border Protection warehouse in Carson, Zeldin pointed to a white bottle with a yellow label reading “SNIPER” — an illegal pesticide product commonly imported from abroad and sold online — that was recently intercepted at the Port of L.A. complex. Sniper contains dichlorvos, or DDVP, a highly toxic insecticide that is not registered or approved for use in the U.S. It is known to cause neurological problems, convulsions and comas, with children particularly at risk.

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Illegal pesticides are cause for concern in California, where they are often associated with illegal cannabis operations. Last year, Siskiyou County declared a local emergency in response to the “escalating threat” posed by illegal pesticides, often fumigants, in illicit cannabis operations.

“These chemicals, when burned, create thick, poisonous smoke that presents serious risks to public health, the environment, waterways, and first responder safety,” the county said.

A 2024 Los Angeles Times investigation found that contraband Chinese pesticides used on cannabis farms is a growing problem in the state.

Customs and Border Protection seized containers of an illegal pesticide from China that were packed with legitimate items.

(Myung J. Chun/Los Angeles Times)

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Much of the illegal product comes through the ports of L.A. and Long Beach, which together handle more than 30% of the nation’s container traffic, officials said. EPA works closely with Border Patrol officials, who flag suspicious cargo containers at the port for further inspection.

CBP spokesman Jaime Ruiz said the agency is using artificial intelligence tools to help scan incoming cargo manifests for potentially illegal items. Thousands of containers are flagged for inspection each year, although that number also includes drugs, counterfeit goods and other contraband in addition to pesticides, he said. He could not immediately say what percentage were illegal pesticides.

Illegal pesticides have at times been found in California agriculture and the California Department of Pesticide Regulation has taken enforcement action against violators. The DPR operates one of the nation’s largest pesticide residue testing programs, analyzing some 3,500 produce samples each year from wholesale and retail stores and other outlets. The state produces about half of the nation’s fruits and vegetables.

Jeff Hall, assistant administrator of EPA’s Office of Enforcement and Compliance, said the issue should be bipartisan.

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“We cannot allow foreign actors to profit by sending toxic and poisonous products into the United States and poisoning American communities,” he said. “This is a message that we should all be able to agree on, especially for pesticides.”

However, the agency’s visit to L.A. arrived at a fractured moment for U.S. pesticide regulation and for the Trump-aligned Make America Healthy Again movement.

On Thursday, the Supreme Court ruled 7-2 in favor of Bayer’s Monsanto, the maker of the powerful weedkiller Roundup, shielding it from thousands of state lawsuits that allege the company failed to warn people the product could cause cancer.

Roundup contains glyphosate, which was classified by the World Health Organization as “probably carcinogenic” in 2015. But the Supreme Court found that the company can’t be sued in state courts because federal agencies — including the EPA — have determined that it’s not likely to cause cancer in humans when used as directed. The EPA has repeatedly approved a label for the product without a cancer warning.

“When people are exposed to pesticides, they deserve honest warnings about the risks,” said Bill Jordan, former deputy director of EPA’s Office of Pesticide Programs, in a statement. “The Court’s decision leaves families, workers, and communities with fewer tools to protect themselves and to recover damages when they are injured by a pesticide.”

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